Background: The school dental screening program has been in existence from the beginning of 20 th century. Its value in encouraging attendance among school children is not fully established. Aim: The aim was to determine the effectiveness of school dental screening on stimulating dental attendance rates among school children in Vikarabad town. Objectives: (a) To compare the dental attendance rates between 6-9 and 10-13 years old age groups, among male and female school children in Vikarabad town. (b) To identify the type of dental treatment received by the school children. Materials and Methods: A randomized controlled trial was conducted among school children aged 6-13 years old from 16 schools that were randomly selected and divided into two groups. Eight schools had a dental screening program (study group = 300 children) and had blanket referral cards and 8 schools that did not have the intervention (control group = 300). The dental attendance rates were determined after 3 months of follow-up period by evaluating the blanket referral cards for the study group and by an oral questionnaire for the control group. Results: The dental attendance rate was 27% for the study group and 18% for the control group which is statistically significant. The attendance rate was higher among 10-13 years of children both in test group and control groups. Among the children who visited the dentist, 53% in the control group and 69% from the test group got simple amalgam and glass ionomer cement restorations. Conclusion: The dental attendance rates were improved following school dental screening.

In India, children form about 38% to 40% of the total population, and 80% of them have high levels of dental diseases. [1] School dental screening is seen as a vehicle for bringing children with dental needs in contact with dental services. Dental screening of school children can help disadvantaged children by informing about their dental health status and motivating them to obtain appropriate treatment. Thereby school children may arrive at the dental practice which in turn increases dental attendance rates. [2]

Screening is defined as the preassumptive identification of unrecognized disease or defect by the application of tests, examinations or other procedures that can be applied rapidly. The primary aim of the school dental screening is the detection of disease at a stage earlier than that at which the patient would normally present for treatment. [3] The earliest call for the dental screening of children in the school setting came in 1885, when William Fisher, a Dundee scientist called for the compulsory attention of the teeth of school children. [3] WHO recently supported screening of children for dental diseases and conditions in the school setting to help reduce costs of dental service provision and to support planning and provision of school oral health services. [4],[5]

Since the school dental screening requires cooperation from education departments and schools and is time, personnel and work intensive, the question of its effectiveness is an interesting one. Stimulating dental attendance among those children with the greatest treatment need in a cost benefit way is a challenge for school dental screening. Hebbal and Nagarajappa in 2004 demonstrated that screening and motivation significantly improved the percentage of school children who sought dental care. [1] In a study conducted by Donaldson and Kinirons 2001, [6] it was found that dental attendance was 45.5% among study group and 27.6% in the control group in the 2 months following screening. Cunningham et al. 2009 [7] demonstrated that neither traditional screening nor a letter home to unregistered children resulted in a significant rise in registration rates in 12-13-year-old compared with a control group of children who received no intervention. Milsom etal. in 2006 [2] concluded that school dental screening has a minimal impact on dental attendance and only a small proportion of screened positive children receive appropriate treatment. The programme fails to reduce inequalities in utilization of dental services. [2] In India, there is little evidence to show the effectiveness of school dental screening on stimulating dental attendance rates. It requires studies on these issues before taking a decision.

Hence, this study was undertaken to determine the effectiveness of school dental screening on stimulating dental attendance rates among school children in Vikarabad town.

The objectives of this study were:

To compare the dental attendance rates between 6-9 and 10-13 years old age groups, among male and female school children in Vikarabad town

To identify the type of dental treatment received by the school children.

Materials and Methods

A randomized controlled trial was conducted among school children aged 6-13 years old of Vikarabad town of Ranga Reddy district, Andhra Pradesh India. Before the start of the study, a complete list of all the registered schools in Vikarabad town was obtained from the office of the Mandal Educational Officer. There were a total of 91 schools, consisting of 67 government schools and 24 private schools. Of these, 24 private schools and 13 government schools were almost equidistant from the dental hospitals regarding the accessibility to dental care.

These 37 schools were then subjected to a two stage sampling technique for the selection of schools. In the first phase, 16 schools were selected by lottery method and in the second stage these schools were assigned randomly to either study or control group. The required sample size was determined based on scientific literature with similar study setting undertaken in Davangere, India in which the attendance rate was 27% following screening (Hebbal etal. 2004). The study population was made up of 300 school children in the study group and 300 school children in the control group. The school children were divided into two age groups, 6-9 years and 10-13 years group. All eligible school children aged 6-13 years attending the registered schools in the study area were included. Those children whose parents decline the invitation to participate and children who refuse to be screened on the day were excluded. Those children who were present at the time of outcome measurement but not at the baseline examination were also excluded from the study. Informed consent was obtained from the parents of all the participating children, and ethical clearance was obtained from the Institutional Review Board.

All the school children in the study group who were present on the day received screening for various dental diseases/conditions according to American Dental Association specified type III clinical examination method. The control group receives no such intervention. A child with positive screening had a referral card to his/her parent. Information on the card included dental hospitals name and address in Vikarabad town, clinical findings on screening, and the treatment required by the child.

The dental attendance rate among the study group was calculated during the 3 months follow-up period from August 2012 to October 2012 by evaluating the referral cards. In order to obtain the dental attendance rate among the control group, 300 children were randomly taken and asked, whether they visited the dentist during the past 3 months. They were examined, and dental findings were noted.

Data were processed using Microsoft Excel 2007 and analyzed using SPSS version 18.0. A level of P < 0.05 was adopted to determine the statistical significance between different groups. Chi-square test was used to test the significance of the difference between two proportions.

Results

[Table 1] shows the total number of children examined in the 6-13 years old age group among both genders. The dental attendance rates in the study and control groups were 26.66% and 18% respectively. The difference in the attendance rate was statistically significant (P = 0.047).

[Table 2] shows the dental attendance rate according to age and gender. In both groups as the age increased, the dental attendance rates were also increased, which was statistically significant only in the study group (P = 0.028). Among male and female school children in both the groups, the result was not statistically significant (P = 0.135).

In this study, the dental attendance rate among the study group was 27% but was only 18% in the control group. The results were similar to the studies conducted by Donaldson and Kinirons, [6] Hebbal and Nagarajappa [1] and Fox. [8] They demonstrated that the school dental screening was capable of stimulating dental attendance rates and may be used to decrease dental health inequalities.

Although the children in the study group were informed about their oral health and were urged to undergo the treatment, the response rate was only 27%. The results were similar to the studies done by Donaldson and Kinirons, [6] Zarod and Lennon [9] and Harding and Taylor. [10] They explained various reasons for low utilization of dental services like cost of dental treatment, the value placed on dental health, mother's educational level, ethnic grouping, and dental anxiety. Many of these factors have proven difficult to modify, and some authors advocate a sociopolitical approach. Parents will have to bear other expenditures such as the cost of transportation to receive the treatment, and they may prefer not to see their child absent from school to get the dental treatment, as appointments are scheduled during school hours only. Some parents are also concerned about quality of treatment given. [6],[11]

In both groups, no significant difference was found among males and females, though females in the test group and males in the control group had higher dental attendance rates which may be due to their self-perceived need for treatment. These results were in contrast to the study conducted by Hebbal and Nagarajappa [1] in which males had higher dental attendance rates compared to females. They concluded that historically, in a country like India where more preference is almost always given to the male child over a female child in all walks of life, it was not surprising to see that attendance for treatment was greater among males than among females.

The dental attendance rates in the study group were higher among 10-13 years of age group than 6-9 years of age. The results were similar to the studies conducted by McCunniff et al. [12] and Hebbal and Nagarajappa [1] in which they explained that older child feel more independent and becomes self-conscious about his esthetics and is influenced by his or her peer groups, and the child may come for treatment without waiting for a parent to accompany him or her.

Zarod and Lennon [9] concluded that most people have an attitude that the primary dentition is not of much importance as it will be replaced by the permanent dentition. In addition, the caries in permanent teeth in young children will usually be in the initial stages and may not cause discomfort to the child so that parents may be unaware of treatment needs at this age. [11] These reasons might have contributed to low attendance rate among the 6-9 years old children even though they were aware of the need for dental treatment.

In this study, most of the children who attended the dentist either from the study or control group presented with dental caries in contrast to the other dental diseases or conditions. The results were similar to study conducted by Hebbal and Nagarajappa [1] in which they explained that people in India tend to associate dentistry with treatment of carious teeth only, rather than with gingivitis or fluorosis, malocclusion that cause hardly any discomfort to the patient.

The nonrespondents from both the groups would have been less likely to have attended the dentist in 3 months follow-up period. Therefore, the absolute dental attendance rates in both the groups would probably have been lower. In the recent years with greater demands being placed on dental budgets, school dental screening has found itself coming under pressure to justify its significant costs. Targeting may be one way in which school dental screening could be developed in the future. [6]

This study had the follow-up period of 3 months. Zarod and Lennon [9] suggested that 3 months are sufficient for dental attendance and treatment to take place. In a study conducted by Milsom et al., [2] it was found that the school dental screening was not effective in increasing dental attendance rates even though the follow-up period was 4 months, and they argued that 4 months interval between baseline and outcome examinations was insufficient for dental treatment to have been completed. In a study conducted by Hebbal and Nagarajappa [1] it was effective when the follow-up period was 2 months because oral health education along with screening and the offer of free treatment served as motivational factors for the school children to seek dental treatment. [1]

There is some evidence to support that vigorous follow-up of children does lead to improved dental attendance rates. However, the acceptability to parents and the cost effectiveness of putting significant resources into elaborate follow-up procedures would need to be scientifically assured. [2],[13]

School dental screening is a process that starts with the identification of the "at risk" children and ends with the successful treatment of the conditions identified by the screening and only when each step in the process is quality assured will the school dental screening program meet the exacting standards set by the national screening committee. [14] Any changes in dental screening in schools should build in its best features and take account of the views of all involved, making it a more positive and relevant contribution to primary dental care. [15]

Conclusion

The results of the study demonstrated that the school dental screening significantly increases the dental attendance rates. Furthermore, School dental screening together with the child's previous attendance for checkups and the time since the parents last dental visit, is one of the strongest predictors of dental attendance. The only one of these factors that lies within the dentist's control is screening. Further studies needed to identify the factors that hinder seeking dental care.

Acknowledgments

We would like to thank the school children, teachers, and parents for their cooperation during the study.

Donaldson M, Kinirons M. Effectiveness of the school dental screening programme in stimulating dental attendance for children in need of treatment in Northern Ireland. Community Dent Oral Epidemiol 2001;29:143-9.